Rubella

rubella

1. Rubella By : Dr. Saurabh Agrawal

2. HISTO R Y - RUBE LLA Discovered in 18th century - t h ought t o b e varia n t of m e asles The Teratoge nic pro p erty of the i n fection was d o cumen t ed b y an A u stralian op h t h almolo g ist Norma n McAlister Gr e gg , in 1941 The virus was isola t ed in 1962 2 04/04/2015

3. Introduction Fro m Lat i n m e an i ng "l i ttl e red" An atte n uate d vaccine was developed in 1967 Firs t de s cribe d as disti n ct cli n ical ent i t y in G e rman li t erature 3 04/04/2015

4. EPID E MIOLOGY 17 04/04/2015  Oc c urs worldwide  T h e vir u s te n ds t o pea k in coun t ries with te m perat e cl i mates  C o m m on in children a g es 5 -10 ye a rs old  Huma n are only kno w n reservoir.  Hos t - 3 -10 yrs  Source of in f ec t ion – Re s pir a t o ry secretion  Infants with CRS m ay shed vir u s for a yea r or m o re  I m munity – l i fe long  Oc c urs round t h e ye a r, pea k in l a t e win t er and s p ring season  Transmiss i on – dro p let, ver t ic a l t ransmiss i on  I.P – 2 -3 weeks aver a g e 18 da y s  R u bell a is w orld wide in d i stribution  Epidemics occur every 4 -9 ye a rs.

5. Ru b ella Vi r us Togavirus RNA virus O n e an t ige nic ty p e Rapidly i nact i vated b y chemical agen ts, low p H , hea t and ultravio l et li g ht 4 04/04/2015

6. AGENT FAC T ORS A- Agent C a usative a g e n t : R u bella vir u s ssR N A V i rus of t h e Togaviridae Family ge n u s R u b i virus One antigenic t y pe Diamet e r 50 – 70 nm En v elo ped S p he ric a l Virus carr y hemag g l u t in i n Viru s multiply in the cytoplasm of infecte d cell. Highl y s e nsitive to he a t , extre m es of pH & u v light. At 4 °C, v ir u s is rela tively s t able for 24 hou r s. 6 04/04/2015

7. AGENT FACTO R S cont. 7 04/04/2015 B - So u rce of i nfect ion C ASES Su b cli n ical Cli nical Con g eni t al from i nfec ted preg n ant wom e n t o fet u s . There is n o k n own carrier state. C - Period of commu n icabi l ity It proba b ly exte nds from a wee k be f ore symptoms t o about a week af ter rash ap p ears. I n fec tivi t y is greatest when t h e rash is erupti n g.

8. HOST FACTORS A - Age Disease of chil d h o od 3-10 yr s age group. Fo l lowi n g widespread imm u n i zati o n campaigns persons older t h an 15 yrs account for 70% cases in developed countries. B- Imm u n i ty O n e at t ack results in life lo n g imm u n i ty. I n fants of im m une mothers are protected for 4 - 6 mo n t h s. In I n dia, about 40% of chi l d b eari n g age grou p wom e n are suscept i bl e t o ru b ella. 8 04/04/2015

9. Immunit y - Ru b ella Antibodies appe a r in ser u m as rash fa des an d ant i bo d y titre s raise R a pid r a ise in 1 – 3 we e ks R a sh in a s sociation w ith detection of I g M indicates recent in f ection. Ig G an tibodie s persis t for li f e 9 04/04/2015

10. ENVIRONMENTAL FACT O RS Disease usually occurs i n seasonal patte r n , during the lat e winter & s p ring. 10 04/04/2015

11. Mode o f Trans m ission  Person to p erso n - via respira t ory rout e : - Dr o plet f r o m no s e & th r o a t Dropl e t nucl e i (a e r o s o l s ) Maint a in in h u man po p ulat i on by chai n t r a nsmis s i o n.  Acquired du r ing preg n anc y - ver t ical tr a nsm i ssion : - Viru s can enter via th e Pl a centa & in f ect the f o etus in utero (Co n genit a l Rubella Syndrome). 11 04/04/2015

12. Incubation period Between 1 4 -21 days 12 04/04/2015

13. Patho g enes i s Conti n u e d … … Respiratory Tr act Skin Lym ph N o des J o ints Place n t a or Fe t us Cough Mi n or sore t h roat Ra s hes Le s ions M i ld art h ralg i a art h rit i s Placenti tis Fetal Damage Lymp h adeno p at h y 14 04/04/2015 R u be l la V irus Dev e loped in th e n a soph a ry n x

14. Ru b ella Clinica l Featur e s Inc u ba t ion perio d 14 d a y s (ra n g e 1 2 -23 d a y s ) Low gra d e fever Lym ph a de n opat h y in se cond week Maculopapular rash 14-1 7 d a y s after exposure 18 04/04/2015

15. SIG N S AND SYMPTOMS R AS H - A fte r an inc u batio n perio d of 1 4 -21 days, t h e primar y symptom of ru b ella virus i nfec tio n is t h e app eara nce of a ra s h (exan t h em a) on t h e face whi c h sp r e a ds to t h e tr u n k a n d l i mbs and usually fades after t hree days with no s t ain ing or pe eling of t h e skin. The skin manife s t a tion s are called " BL U EBERRY MUFFIN LESIONS . " 19 04/04/2015

16. SIG N S AND SYMPTOMS continue d …. LY M PH NOD E - Te n d er lymp h a d e n opat h y (p arti c u l ar l y po s t er i or a ur i cu l ar an d suboc c ipital ly m p h n o d e s ) p ersist for u p t o a we e k. 20 04/04/2015

17. SIG N S AND SYMPTOMS TEMPERATUR E - Feve r rarely ri s es above 3 8 o C ( 1 .4 o F) 21 04/04/2015

18. Other manifestation s & complications M a y p r oduce t ran s ient Arth r itis , particul a r in wo m en. Se r iou s compli c ations are- Thrombocytopenia P urpura En c eph alitis 22 04/04/2015

19. Pathog n omoni c Sign F o rchh e imer’s Spot Fl e etin g enan thema Pin poin t or larg e r pet e chiae th at u s u a lly oc c u r on th e soft pal a te in 2 0% of pat i en ts Similar spots can b e seen in me a sle s an d s c arl e t fe v er. 23 04/04/2015

20. Salt & Paper retinopa t hy 24 04/04/2015

21. Systemic events o f Ru b ella Infe c tion 25 04/04/2015

22. Main Clinica l Events During Pregnancy 26 04/04/2015 The c l inic a l events o c curring in the neo n atal a g e is more impor t ant and divided int o tw o m ajor g r oups-  1 C on g enital Rubella  2 Post N at a l R ubel l a

23. Co n genita l Ru b ella Syndrome (cr s) Occ u rs dur i ng t h e first t rime s t er of preg n a ncy. Affects t h e developme nt of t h e fe t us. m a y l e a d t o several bi r th defect s . Infection m a y affect all org a n s . May lead t o fe t al dea t h or prem a ture delivery. Severity of d a m a g e to fe t u s dep e n ds g es t a t ion al a ge. In fan t s: v i r u s is isola t ed from u r ine a n d feces. 27 04/04/2015

24. Ru b ella inf e ction – At var i ous trim e ste r s 28 04/04/2015 I s t trimeste r i nfec tio ns lead t o a b n o rmalities in 85 % of cases and greate r damage t o orga ns 2 n d trimeste r i nfec tio ns lead t o de f ects in 16 % > 20 weeks of pre g n a ncy fetal defects are uncommon H o weve r R u b ella i nfec tio n can also l ead t o fetal deaths, and spo n ta n eous abortio n . The i n trauter i n e i n fectio n s lead t o viral e x creti o n in various secretion in newbor n u p t o 1 2 - 18 mont h s.

25. Ru b ella inf e ction & Chanc e of CRS 29 04/04/2015 0– 28 days bef o re concepti o n - 4 3 % c h ance 0– 12 we e ks after concepti o n - 5 1 % c hance 13– 26 we e ks a fter concepti o n - 2 3 % c h ance In fants a re n ot generally a f fect e d if ru b ella is cont r a c ted d urin g the thi r d tri m ester

26. Post nat al Rubella Occ u r s in N eona t es and Childho o d Adul t inf e ction o cc u rs thr o ug h m uc o sa of t he uppe r respirato r y tra c t spread to cervical lymph nodes Vire m ia d e velops a f ter 7 – 9 day Las t s for 13 – 15 days L e ads to d e velop m ent of antib o dies The appearance of antib o dies coin c ides t he appea r ance of suggestive i mm un o logic b asis for t h e r ash In 20 – 50 % cases o f pri m ary inf e ctions a r e su b clinical. 04/04/2015 30

27. Ru b ella Cas e De f inition 31 04/04/2015 Acute onset of g enerali z ed ma c ulopapular rash and tempe r ature of >37 . 2 C (>99 F) , i f m easured with or without art h ritis / arth r algia or lymphadeno p athy or conjunctivitis.

28. Clinica l Featur e s  Rash at b ir th  De a fness  Cata r acts  He a r t def e cts  M icrocephaly  Ment al reta r da t ion  Bone al tera t ions  Live r and sp lee n dam age 32 04/04/2015

29. Cata r act H e aring Defects Se n sor yneur o n al deaf n ess Classical Triad Classic a l T r iad of Ru b ella 33 04/04/2015

30. Other Ab n ormal i ties T ransient low birth w e i ght, hepa t o s pleno m egal y , thro m boc y topenic purpura,bone l e sion s , m en i ngoen c eph a l i t is , hep a t i t i s, ha e m ol y tic an e m i a , pneumonit i s , l y m phad e nopa t h y Per m an e nt sept a l de f e c t) E y e Def e c t s severe m y opi a ) Other De f e c ts ( m i c ro c eph a l y , ( r e t i nopa t h y , cata r a c t , m i c roo p th a lm ia g l au c o m a, di a b etes m e l l i t is, t h y r o i d disorders, der m a t ogl y ptic abnor m a l i t i e s Sensorineur a l de a fnes s , Ment a l re t arda t ion, Diab e t e s Mel l i t us, th y roid disorder D e v e l o p m e ntal 34 04/04/2015 S ensorineural d e afnes s , Hea r t D ef e c ts (p e ri p heral pul m o na r y stenosis,pulmona r y va l v u l a r s t e nosi s , p a t e nt duc t us a r t e r i osu s ,ven t ri c u lar

31. Risk s o f ru b ella infection during pregnancy Pre c onception m inimal risk 0- 12 wee k s 100% ri s k of fet u s bein g con g enitally infe c te d result i ng in m ajor con g enital abnor m al i t ie s . Spontaneo u s abortion occurs in 20% of ca s e s . 13- 16 wee k s Deaf n ess & retino p at h y 15% ca s es. After 16 weeks 3 Nor m al deve l op m ent, s l ight ri s k of deafness & retinopathy 5 04/04/2015

32. Di a gnosis of R ubella in Adults 36 04/04/2015 Clini c al D i agnos i s i s u nreli a b l e M a n y vir a l i nfe c ti o n s mi m ic R ub e lla Spec i fic diagnosis of infe c ti o n w i t h - 1 I solation of virus 2 Evidence o f seroc o nv e rsion

33. Isol a tion and Identi f ication of virus Na s opharyn ge al or throa t swabs ta ken 6 days prio r or a f ter app e ar a nc e of rash is a goo d source o f Rub ella virus Using c ell cultu red in sh ell vi a l an tig e n s c an b e detected by I m m unof l ur e secent met hods 37 04/04/2015